Friday, June 15, 2007

Talking Dirty

“I don't wake up for less than $10,000 a day.”  Linda Evangelista

Warning: The following may not be suitable for people who think their doctor goes to work out of the goodness of his heart.

It’s time to address the 800 lb gorilla in the room: Money.

Universal government health insurance has, for some, divorced the delivery of medical care from payment for that care. For virtually all services I provide, patients are never aware that I get paid by submitting a bill under their name to the Saskatchewan government. It's a very sanitized process. I'm so used to it that I’m sometimes uncomfortable discussing payment for uninsured services with patients.   

Some physicians receive a salary, but many are fee-for-service, i.e., we get paid a fixed amount for each office visit or surgical procedure. We need to discuss this aspect of medical practice openly as it will be on physicians' minds as they consider adopting Advanced Access. Will their practice revenue rise or drop? Will there be any other non-monetary effects?

If we just consider Advanced Access as a way to balance demand and capacity, then it should be revenue-neutral. (Working down the backlog will increase fee-for-service revenue temporarily as more services are being provided.)  But AA has some benefits that aren’t immediately obvious.

In our practice, reshaping demand promises to increase revenue while maintaining patient care and satisfaction. We’ve done a preliminary survey of the urologists regarding their recall practices. Some patients require regular specialist review (internal demand) for ongoing problems, such as cancer or kidney stones. However, individual recall practices are often governed as much by habit as by evidence found in the medical literature. Our survey shows some variation in practice among the urologists. If we can agree that the less frequent recall practice is acceptable, this will free up more appointment time to see new consultations.

Increasing the ratio of new consultations to review visits improves our revenue because the new consultation fee is just over twice that for review visits. We also want to consider circumstances where patient follow-up can be carried out by family physicians, with specific advice from us. Once again, this will free up time for us to see new referrals, provide patients with good continuity of care with their primary physician and save travel time for many patients.

AA has reduced the no-show rate in many practices. This increases revenue in a fee-for-service practice.

It’s hard to set a dollar value on reduced administrative hassle, but it certainly has value. Every day, I review new referrals to decide whether the assigned appointment is appropriate for the patient’s problem. If the family doctor’s letter indicates an urgent problem, I may ask my staff to squeeze the patient into a slot within the next 2 weeks. If (under AA) all new consultations are seen within 2 weeks regardless, I won’t need to spend time on this triage. Referring physicians will sometimes call to ask for their patient’s appointment to be moved up. AA should save them and me the time spent on those phone calls. That adds up to getting home earlier.

If one of my current patients can't get a prompt appointment to discuss his ongoing problem, he'll leave a message for me to call him. That’s not always optimal, as it may be days before I get through a long list of calls, plus it's annoying to play phone tag. Returning phone calls can add a couple of hours to the end of a long day. And (in keeping with this week's theme), according to the rules of Saskatchewan's government health insurance, I don't get paid for advice given over the phone. I don't want to drag people in from hundreds of miles away just to ask me a quick question, but I would like to be able to offer a prompt office visit to people who live close to Saskatoon.

As I’ve discussed before, our current system wastes staff effort in reworking appointments. A more efficient system would reduce this burden and free up staff to undertake other work or, in some offices, may reduce the number of staff required.

Having office appointments booked for months in advance makes for a very rigid system. If I want time off for holidays or conferences, it's difficult to arrange on short notice. Our staff would have to rebook many patients – up to 50 if I take a week off.  Using AA, most office days will only be filled 2 weeks in advance. We'll have a lot more flexibility to schedule meetings, holidays, and conferences.

Particularly important for surgeons is the ability to use extra OR time. It's fairly common that another surgeon isn't able to use her usual day of OR time, and that time is offered to other surgeons. With our old system, we were reluctant to reschedule a whole day of appointments and may have declined extra OR time. Our new system should be nimble enough to take advantage of extra resources that are available on short notice. How better to motivate surgeons to adopt Advanced Access than to see our group gobbling up all the extra OR time? Adapt or perish! Darwin rules!

P.S. Check out our national media exposure.


  1. Originally posted by Eric E. (Saskatchewan Health) 6/18/2007 8:48 AM

    Thanks for sharing your thoughts in this way. It's interesting to see some of the business issues, as well as the medical issues and client service issue, that need to be dealt with in running a practice.

  2. Originally posted by Stephen Berman 6/21/2007 11:02 AM

    As a patient, and subsequently a member of Dr. K. Visvanathan's advanced access committee, I was at first skeptical as to what might be accomplished, what I could possibly contribute, and the substance of the prospect of eventually seeing more patients in a more timely fashion. I did not have an in depth view of the workings of the medical community and probably had almost all of the same skepticism that is held by the general public. When I told friends of my involvement some expressed doubts about a positive outcome and about the system in general. Many thought that without more doctors better results simply could not be had.

    My experience with the committee, and the results obtained thus far, has taught me this skepticism is not warranted. The professionalism and deep concern of the committee for patients is to be saluted.

    Not only do they want to make a better, and more timely, system for patients, but they are willing to work harder for quite some time (often making personal sacrifices) to accomplish this. Both the doctors and the office staff play a very important role here and I have come to understand how important the partnership between the two is in the success of the system.

    The Health Quality Council, through Karen Barber, also plays a central role in the work of our committee. Through tracking various statistics, and bringing to the committee a deep understanding of how successes with advanced access in other places has worked well, the committee gets direction, as well as inspiration, on how to accomplish our goals in this particular practice. I think all on the committee make vital contributions. Empowering patients and gaining better and quicker access to the specialists in the practice are the primary goals of the committee. I salute this work and am glad to be a small part of it.